Elder Abuse in the United States

ARTICLE #12: ELDER ABUSE

In the United States, the issue of elder mistreatment is garnering the attention of the law enforcement, medical, and research communities as more people are living longer than ever before. This trend is expected to increase, as the U.S. Census Bureau projects that more than 62 million Americans will be age 65 or older in 2025, an increase of 78 percent from 2001, and more than 7.4 million will be age 85 or older, an increase of nearly 68 percent from 2001 ( McCoy and Hansen, 2004 ). This aging population will require more care and protection than is currently available or possible.

The National Research Council defines elder abuse and mistreatment as "(a) intentional actions that cause harm or create a serious risk of harm to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder, or (b) failure by a caregiver to satisfy the elder's basic needs or to protect the elder from harm" ( Bonnie and Wallace, 2003 ). This definition includes financial exploitation of the elderly as well as physical abuse or neglect.

NIJ's primary objectives regarding elder mistreatment are to identify emerging promising practices and evaluate their effectiveness in improving prevention, detection, and intervention efforts.

Identifying Elder Abuse
NIJ's Elder Mistreatment research program—supported in part by the U.S. Department of Justice's Elder Justice and Nursing Home Initiative—has produced significant data on the following issues:

Bruising in the Geriatric Population
Documenting normal bruising patterns in this population is the first step toward differentiating accidental from suspicious bruising. An NIJ-funded study found that:

Accidental bruises occur in a predictable pattern.
Most accidental large bruises are on the extremities.
The initial color and appearance of bruises changes over time and is less predictable than previously thought.
Individuals who are on medications known to make bruising more severe and those with compromised functional ability are more likely to have multiple bruises (Mosqueda, Burnight, and Liao, 2006).

Determining Abuse as a Cause of Elder Death
An NIJ-funded study examined how medical examiners make determinations in cases of suspicious elder deaths and found that they rarely can differentiate symptoms of illness from signs of abuse in elderly decedents. As a result, signs of abuse that are commonly recognized in younger decedents are missed in elders, and abuse is rarely seen as a cause of death. These findings call for additional research on both the decisionmaking practices of medical examiners and the forensic markers of elder mistreatment, and also highlight the need for medical examiners to receive additional training on this issue (Dyer, forthcoming).

Potential Markers for Elder Mistreatment
Researchers in Arkansas (Lindbloom et al., 2005) identified specific characteristics within four categories of markers that investigators can look for to determine whether elder mistreatment is occurring or has occurred—see table Potential Markers for Elder Mistreatment.

This study is still ongoing; the researchers hope to determine whether the Arkansas Long-Term Care Reporting law has actually made a difference in quality of care, further elucidate markers, and development of an adaptive investigative model for coroners and medical examiners (Lindbloom et al., 2005).

Addressing Elder Mistreatment
Some jurisdictions have developed innovative approaches to improve system response to elder mistreatment, such as special elder abuse prosecution units, elder fatality review teams, and the expansion and improvement of statutes that mandate abuse reporting for vulnerable adults. Although these approaches show promise, they are in the nascent stages of their development and have not been rigorously evaluated.

For example, researchers have examined implementation of the Arkansas law giving county medical examiners the authority to investigate deaths occurring in long-term care facilities (LCF). [1] They conducted focus group interviews with medical examiners, coroners, and geriatricians from 27 States to determine their involvement in investigations into the deaths of LCF residents. Although Lindbloom's findings suggest that the Arkansas law had a positive impact on attention to elder mistreatment and the quality of care of LCF residents in Pulaski county, whether care has improved State-wide is not clear because of differences in implementation.

Researchers in Arkansas identified specific characteristics within four categories of markers that investigators can look for to determine whether elder mistreatment is occurring or has occurred—see Potential Markers for Mistreatment (Lindbloom et al., 2005).

The second phase of this study concluded in 2007. The resulting data indicates that the Arkansas Long-Term Care Reporting law, which mandated that all deaths that occur in nursing homes in Arkansas be officially investigated, has not made a difference in quality of care in the state. The project also revealed additional factors associated with higher level of mistreatment suspicion, including family dissatisfaction with care; minority race; tube feeding; the presence of a severe pressure sore, or recent ostomy (Lindbloom, 2008).

The Office for Victims of Crime (OVC) teamed up with the American Bar Association to produce a replication manual to aid elder abuse fatality teams in reviewing the causes of elder deaths and enhancing the response of community agencies to elder victims of abuse.

Potential Markers for Elder Mistreatment
The table below shows specific characteristics identified by researchers in Arkansas within four categories of markers that investigators can look for to determine whether elder mistreatment is occurring or has occurred.

Potential Markers to Identify Elder Mistreatment

Physical Condition and Quality of Care

Documented but untreated injuries.
Undocumented injuries and fractures.
Multiple, untreated, or undocumented pressure sores.
Medical orders not followed.
Poor oral care, poor hygiene, and lack of cleanliness of resident
(e.g., unchanged adult diapers, untrimmed finger and toenails).
Malnourished residents that have no documentation for low weight.
Bruising on nonambulatory residents; bruising in unusual locations.
Family has statements and facts concerning poor care.
Level of care for residents with nonattentive family members.

Facility Characteristics

Unchanged linens.
Strong odors (urine, feces).
Trash cans that have not been emptied.
Food issues (cafeteria smells at all hours; food left on trays).
Past problems.

Inconsistencies between—

Medical records, statements made by staff members, or what is viewed by investigator.
Statements given by different groups.
The reported time of death and condition of the body.

Staff Behaviors

Staff members who follow the investigator too closely.
Lack of knowledge or concern about a resident.
Evasiveness, both unintended and purposeful, verbal and nonverbal.
Facility's unwillingness to release medical records.

Exploitation of the Elderly
No national reporting mechanism exists for tracking the financial exploitation of elders. According to a 1998 study by the National Center on Elder Abuse, financial abuse accounted for about 12 percent of all elder abuse reported nationally in 1993 and 1994 and 30.2 percent of substantiated elder abuse reports submitted to Adult Protective Services in 1996 after excluding reports of self-neglect (National Center on Elder Abuse, 1998). A 2000 survey of the National Association of Adult Protective Services Administrators conducted for the National Center on Elder Abuse (Teaster, 2003) found that financial exploitation comprised 13 percent of the mistreatment allegations investigated. Many experts in the field, however, believe that the level of elder exploitation may well exceed what has been reported to authorities and documented by researchers.

Sexual Abuse of the Elderly
Sexual abuse is one of the most understudied aspects of elder mistreatment. An NIJ-sponsored study (Burgess and Hanrahan, forthcoming) that examined elder sexual abuse found that:

Elderly sexual assault victims were not routinely evaluated to assess the psychological effects of an assault.
The older the victim, the less likelihood that the offender would be convicted of sexual abuse.
Perpetrators were more likely to be charged with a crime if victims exhibited signs of physical trauma.
Victims in assisted living situations faced a lower likelihood than those living independently that charges would be brought and the assailant found guilty.

Other Web Resources on Elder Abuse
NIJ does not exercise control over external Web sites. Read our Exit Notice.

Administration on Aging
One of the Nation's largest providers of home- and community-based care for older persons and their caregivers. Its Web site provides information about the Older Americans Act, Eldercare Locator, and other aging-related topics and services.

Bureau of Justice Statistics
The United States' primary source for criminal justice statistics, including statistics on criminal victimization and crime characteristics.

Division of Violence Prevention
A division of the National Center for Injury Prevention and Control (NCIPC), established by the Centers for Disease Control and Prevention. DVP works to prevent injuries and deaths caused by violence. See NCIPC's Web pages on elder abuse and maltreatment and injuries among older adults.

National Institute on Aging
One of the 27 institutes and centers of the National Institutes of Health, NIA conducts high-quality research on aging and special problems and needs of the aged.

Office for Victims of Crime
Enhances the Nation's capacity to assist crime victims and provides leadership in changing attitudes, policies, and practices to promote justice and healing for all crime victims. See OVC's publications and resources for elders.

National Criminal Justice Reference Service
A federally funded resource offering justice and substance abuse information. Spotlight on Family Violence provides detailed information related to all forms of family violence, including elder abuse. See also Special Populations, Elderly.

Help for Elders and Service Providers

Clearinghouse on Abuse and Neglect of the Elderly
CANE is the Nation's largest computerized collection of elder abuse resources and materials, with almost 5,000 holdings.

Elder Abuse Forensic Center
Staffed by professionals from legal, medical, social services, and law enforcement agencies. The center seeks to better understand, identify, and treat elder abuse; determine more efficient ways to prosecute elder abuse cases; and prevent elder abuse through greater awareness and education among professionals working with this population.

National Academy of Elder Law Attorneys, Inc.
Assists lawyers, bar organizations, and others who work with older clients and their families. Provides information, education, networking, and assistance concerning the specialized issues involved with legal services to the elderly.

National Adult Protective Services Association
Provides State Adult Protective Services program administrators and staff with a forum for sharing information, solving problems, and improving the quality and availability of protective services for disabled adults and elderly persons who are abused, neglected, or exploited.

National Clearinghouse on Abuse Later in Life
A leader on program development, policy, and technical assistance and training that addresses the nexus between domestic violence, sexual assault, and elder abuse or neglect.

National Committee for the Prevention of Elder Abuse
An association of researchers, practitioners, educators, and advocates dedicated to protecting the safety, security, and dignity of the elderly. Funded by Congress, the Committee is one of six partners that make up the National Center on Elder Abuse.

National Center for Victims of Crime
A leading resource and advocacy organization for crime victims.

National Sexual Violence Resource Center
A comprehensive collection and distribution center for information, research, and emerging policy on sexual violence intervention and prevention. NSVRC provides an extensive online library, and customized technical assistance, and coordinates National Sexual Assault Awareness Month initiatives.